A Small Number of Surgeons Perform the Large Majority of Uncommon Nerve Decompression Procedures.

BACKGROUND: Notable surgeon-to-surgeon variation in rates of uncommon surgery can reflect appropriate concentration of expertise with technically difficult or risky procedures that address problematic impairment due to objective pathophysiology. Examples include vascularized tissue transfer or transplantation to address complex tissue loss and release of bony elbow ankylosis. Perhaps more problematic is notable variation in straightforward, discretionary surgeries intended to alleviate pain, offered in the absence of objectively measurable pathophysiology, and without experimental evidence of benefit over placebo and other nonspecific effects. Evidence of concentration of this type of surgery in the hands of a few surgeons might point to inordinate influence of surgeon opinions on patient behavior. A study of variation in operations for upper extremity peripheral mononeuropathy has the potential to uncover potentially problematic variation. There are billing codes specific to common surgeries that can benefit patients with objectively verifiable neuropathies. And there are billing codes that represent less common nerve decompression surgeries that in many cases are offered in the absence of both objective evidence of pathophysiology as well as experimental evidence that surgery alleviates pain better than simulated surgery. QUESTIONS/PURPOSES: We asked the following questions: (1) Among surgeons who billed a mean of at least 10 carpal tunnel releases (CTRs) per year in patients with Medicare insurance in the United States, how many also performed at least one less common peripheral nerve release and cubital tunnel release (CubTR) per year? (2) Among surgeons who billed a mean of at least one less common peripheral nerve release or CubTR on average per year, what is the median and range of the number of less common peripheral nerve releases and CubTRs and the relative proportion of these compared with CTRs per year? (3) Are there any differences in gender, specialty, and number of CTRs and CubTRs between surgeons who performed at least one less common nerve decompression and surgeons who, on average, performed none? METHODS: Using the Medicare Physician & Other Practitioners - by Provider and Service database, we identified surgeons who perform a minimum of 10 CTRs per year. Because this database has all surgeries billed to Medicare performed in any setting by individual surgeons, it is well suited to the study of surgeon-specific operative rates among Medicare patients. Among 7259 clinicians who billed one or more nerve procedure to Medicare between January 2013 and December 2019, we excluded 120 nonsurgical clinicians, 47 podiatrists, and 1561 clinicians who billed procedures as an organization. Among the remaining 5531 surgeons, 5439 performed at least 10 CTRs on average per year, which we considered representative of surgeons who include nerve decompression surgery as a part of their practice. Among these 5439 surgeons, we calculated the mean number of CTRs, CubTRs, and less common peripheral nerve releases (including decompression of a digital nerve, nerve in hand or wrist, ulnar nerve at the wrist, brachial plexus, and unspecified nerve) per year between 2013 and 2019. Decompression of the median nerve at the carpal tunnel, the ulnar nerve at the cubital tunnel, and, much less frequently, the ulnar nerve at the wrist typically addresses measurable neuropathy. The other nerve releases are often performed for illnesses characterized by pain that are defined, in part, by the absence of experimentally verifiable pathophysiology such as radial tunnel and pronator (or lacertus) syndromes. We counted the number of surgeons who billed an average of at least one less common peripheral nerve release and CubTR per year; the median and range of the number of less common nerve releases and CubTRs and their relative proportion among those subsets of surgeons; and differences in the number of surgeons who performed one or none less common surgery by gender, specialty, and volume of CTR/CubTR surgery. RESULTS: Of 5439 surgeons who performed a mean of at least 10 CTRs per year, 2% (93) performed a mean of at least one less common peripheral nerve release per year among patients on Medicare, 14% (775) at least one CubTR, and 1% (47) performed both. Surgeons who performed a mean of at least one less common peripheral nerve release per year performed a median (IQR) of 7 (3 to 17) per year (with a maximum of 153 per year), representing approximately one less common peripheral nerve release for every five CTRs. Sixty-five percent (4076 of 6272) of all less common nerve procedures were performed by the top 20 billing surgeons. Gender was not associated with doing one or more uncommon nerve releases (women 1% [6 of 413], men 2% [87 of 5026]; p = 0.84), but specialty was, with plastic surgeons leading (6% [20 of 340] compared with 1% [73 of 5087] for other types of surgeons; p < 0.001). CONCLUSION: The observation that a relatively small number of surgeons perform a large majority of the surgery for nerve syndromes conceptualized as accounting for arm pain suggests that most surgeons are cautious about ascribing pain to conceptual nerve compression syndromes and offering surgery. CLINICAL RELEVANCE: An approach to surgical care founded on ethical principles regards this type of notable variation as a signal of inordinate influence of surgeon opinion on patient behavior, suggesting that professional conduct may be supported by safeguards such as checklists that help guide patients to choices consistent with their values unclouded by surgeon beliefs, false hope, and common misconceptions.

Optimizing Outcomes By Optimizing Bone Health.

Orthopaedic surgeons have long been aware of the importance of metabolic bone health for fracture healing; however, recent attention has focused on optimization of bone health before elective surgery and also regarding pathways to ensure patients have appropriate evaluation and treatment for bone health issues. It is important to describe issues of importance to fragility fracture care and prevention and optimization of outcomes before elective or fracture surgery. To address the challenge of who has the time, expertise, and appropriate patient contact to identify and treat patients at risk of bone metabolic issues, one model for a suggested pathway to ensure these patients are identified and treated is outlined.

Nerve Conditions of the Upper Limb: How Not to Miss or Mismanage.

There are several issues associated with nerve compression syndromes of the upper limb; ultrasonography is a useful diagnostic tool. The orthopaedic surgeon should know how to evaluate and treat patients who do not obtain expected relief following carpal or cubital tunnel release, and also be knowledgeable about the workup and evaluation of patients with conditions of debatable pathology and treatment, such as radial tunnel syndrome or pronator syndrome. Recent studies on suprascapular neuropathy include discussions about the pathophysiology and etiology of the condition, its natural history, and who might benefit from surgery.

Integrating Mental and Social Health in Orthopaedic Practice: The Time Is Now.

Tremendous advances have been made in understanding the intimate relationships between physical, emotional, and social health. There is now a substantial body of evidence demonstrating that mental health and social health may have as much influence on patients' symptom intensity and level of capability-the key metrics of success in orthopaedic care-as pathophysiology. But as a specialty the focus remains mostly on biomedical management (which focuses on structural damage and technical solutions), rather than taking a biopsychosocial approach, which involves screening, measurement, and decision making that prioritizes mental and social health concerns. Failure to do so means orthopaedic surgeons fall short in delivering whole-person care. It is important to highlight the biopsychosocial model of health and healthcare; describe the evidence for mental and social health in orthopaedic practice; outline strategies to identify, measure, and manage psychological and social concerns; and provide frameworks to implement comprehensive models of orthopaedic care that promise to benefit patients, populations, and health systems.

Surgical management of osteoarthritis of the hand and wrist.

Osteoarthritis of the hand and wrist is common; varying disease manifestations and a spectrum of symptoms make it imperative to approach treatment strategies in an individualized fashion. In this review, attention is focused upon site specific diagnoses and indications for various surgical treatment strategies.

Surgical management of osteoarthritis in the shoulder and elbow.

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

Editorial Commentary: Elbow Arthroscopy Is a Safe Procedure. Sure.

Elbow arthroscopy is a procedure that is of great potential use and yet also of grave potential risks. To balance the risk-versus-reward consideration, one must be aware of the potential complications associated with this procedure, weigh them against the potential advantages, and understand one's own skills and familiarity with the procedure. There is no doubt that elbow arthroscopy has changed and even revolutionized our management of pathology about the elbow; however, one must bear in mind that this comes at a risk of complications that cannot be reduced to zero.

Hand and Wrist Problems That Can Be Deceptive: Avoiding Snakes in the Grass.

In this chapter, the authors describe hand conditions that can be "bad actors" and provide specific clues to identify these problems, and strategies to assess and successfully treat them. We will review pediatric and adult hand fractures, fractures of the distal radius, and trigger digits.

Scapholunate Ligament Injury: Management Strategies From Occult Injury to Arthritis.

This chapter will explore scapholunate ligament injuries with a focus on injury recognition, diagnosis, the natural history, and options for treatment. Treatment is based upon injury factors, patient factors, and surgeon preference. The classification systems in common use will be discussed, and treatment options will be explored, including nonsurgical, arthroscopic, repair, reconstruction, pain relieving measures, and salvage procedures.

Ethics and Professionalism: The Role of Self-Regulation and Peer Review in Maintaining Hand Surgery's Standards.

The practice of hand surgery is bound by the need for each of us to maintain our profession's high standards by fulfilling our peers' and society's expectations regarding ethical and professional behavior. Our profession is self-regulated by local, state, and national organizations, which provide expectations and standards for practice. This manuscript reviews the resources available from such organizations to foster standards of practice.

Forearm Instability: Anatomy, Biomechanics, and Treatment Options.

The forearm unit consists of the radius and ulna, a complex and interrelated set of joints (distal radioulnar joint, proximal radioulnar joint) and the soft tissue stabilizers between the 3 bones. Distally, this is represented by the triangular fibrocartilage complex at the wrist, proximally by the annular ligament at the elbow, and in the forearm by the interosseous membrane. Disruptions in any of these structures may lead to forearm instability, with consequences at each of the remaining structures.

Where Are the Women in Orthopaedic Surgery?

BACKGROUND: Although women account for approximately half of the medical students in the United States, they represent only 13% of orthopaedic surgery residents and 4% of members of the American Academy of Orthopaedic Surgeons (AAOS). Furthermore, a smaller relative percentage of women pursue careers in orthopaedic surgery than in any other subspecialty. Formal investigations regarding the gender discrepancy in choice of orthopaedic surgery are lacking. QUESTIONS/PURPOSES: (1) What reasons do women orthopaedic surgeons cite for why they chose this specialty? (2) What perceptions do women orthopaedic surgeons think might deter other women from pursuing this field? (3) What role does early exposure to orthopaedics and mentorship play in this choice? (4) What professional and personal choices do women in orthopaedics make, and how might this inform students who are choosing a career path? METHODS: A 21-question survey was emailed to all active, candidate, and resident members of the Ruth Jackson Orthopaedic Society (RJOS, n = 556). RJOS is the oldest surgical women's organization incorporated in the United States. An independent orthopaedic specialty society, RJOS supports leadership training, mentorship, grant opportunities, and advocacy for its members and promotes sex-related musculoskeletal research. Although not all women in orthopaedic practice or training belong to RJOS, it is estimated that 42% of women AAOS fellows are RJOS members. Questions were formulated to determine demographics, practice patterns, and lifestyle choices of women who chose orthopaedic surgery as a specialty. Specifically, we evaluated the respondents' decisions about their careers and their opinions of why more women do not choose this field. For the purpose of this analysis, the influences and dissuaders were divided into three major categories: personal attributes, experience/exposure, and work/life considerations. RESULTS: The most common reasons cited for having chosen orthopaedic surgery were enjoyment of manual tasks (165 of 232 [71%]), professional satisfaction (125 of 232 [54%]), and intellectual stimulation (123 of 232 [53%]). The most common reasons indicated for why women might not choose orthopaedics included perceived inability to have a good work/life balance (182 of 232 [78%]), perception that too much physical strength is required (171 of 232 [74%]), and lack of strong mentorship in medical school or earlier (161 of 232 [69%]). Respondents frequently (29 of 45 [64%]) commented that their role models, mentors, and early exposure to musculoskeletal medicine were influential, but far fewer (62 of 231 [27%]) acknowledged these in their top five influences than they did the more "internal" motivators. CONCLUSIONS: To our knowledge, this is the largest study of women orthopaedic surgeons regarding factors influencing their professional and personal choices. Our data suggest that the relatively few women currently practicing orthopaedics were attracted to the field because of their individual personal affinity for its nature despite the lack of role models and exposure. The latter factors may impact the continued paucity of women pursuing this field. Programs designed to improve mentorship and increase early exposure to orthopaedics and orthopaedic surgeons may increase personal interest in the field and will be important to attract a diverse group of trainees to our specialty in the future.

Elbow arthroscopy: indications, techniques, outcomes, and complications.

Elbow arthroscopy is a tool useful for the treatment of a variety of pathologies about the elbow. The major indications for elbow arthroscopy include débridement for septic elbow arthritis, synovectomy for inflammatory arthritis, débridement for osteoarthritis, loose body extraction, contracture release, treatment of osteochondral defects and selected fractures or instability, and tennis elbow release. To achieve favorable outcomes after elbow arthroscopy, the surgeon should be aware of contraindications, technical considerations, anatomic principles, and the need for proper patient positioning and portal selection. Elbow arthroscopy is an effective procedure for the treatment of inflammatory arthritis, osteoarthritis, and lateral epicondylitis.

Dorsal proximal interphalangeal joint fracture-dislocations: evaluation and treatment.

Proximal interphalangeal joint injuries are common and often can be treated nonsurgically. Some dorsal fracture-dislocations, however, require special attention or surgical management to optimize outcomes. Treatment options for dorsal proximal interphalangeal fracture-dislocations include splinting, percutaneous pinning, fracture fixation, external fixation devices, volar plate arthroplasty, and hemihamate arthroplasty.

The influence of gender on functional outcomes of lower extremity bypass.

OBJECTIVE: Our aim was to evaluate the effect of gender on early and late procedural and functional outcomes of lower extremity bypass (LEB). METHODS: We reviewed the records of 2576 patients (828 women; 32%) who underwent LEB for claudication or critical limb ischemia (CLI) in the Vascular Study Group of New England from 2003 to 2010. Logistic regression and proportional hazards models were used to adjust for potential confounding differences between genders. Morbidity, mortality, graft patency, freedom from major amputation, ambulation, and living status were analyzed postoperatively and over 1 year. RESULTS: Women were older (70 vs 68 years; P < .001), had more hypertension (89% vs 85%; P = .006), less coronary artery disease (35% vs 39%; P = .03), smoking (73% vs 88%; P < .001), and preoperative statin use (60% vs 64%; P = .04). Women were more likely to have CLI (76% vs 71%; P = .003), and ambulate with assistance at presentation (19% vs 16%; P = .02). Morbidity was similar except women had higher rates of reoperation for thrombosis (4% vs 2%; P < .001) without differences in major amputation (2% vs 1%; P = .13) or in-hospital mortality (1.7% vs 1.7%; P = .96). Women and men with claudication had similar 1-year graft patency rates. Women with CLI had lower rates of primary (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.03-1.48; P = .02), assisted primary (HR, 1.42; 95% CI, 1.15-1.76; P = .001) and secondary patency (HR, 1.40; 95% CI, 1.10-1.77; P = .006) during the first year compared with men. Freedom from amputation was similar for men and women with CLI (HR, 1.17; 95% CI, 0.84-1.63; P = .36). There were no differences in late survival between women and men with claudication (HR, 0.89; 95% CI, 0.60-1.31; P = .36) or CLI (HR, 0.94; 95% CI, 0.81-1.09; P = .39). More female claudicants were not independently ambulatory at discharge (30% vs 19%; P = .002) and were discharged to a nursing home (15% vs 5%; P < .001) but these differences did not persist at 1 year. Women with CLI were more likely to be nonambulatory at discharge (13% vs 9%; P = .006) and at 1 year (13% vs 8%; P < .001). More women with CLI were discharged to a nursing home (44% vs 35%; P = .01) and resided there at 1 year (11% vs 7%; P = .02). CONCLUSIONS: Women have complication rates similar to men with inferior early and late functional outcomes after LEB. The reduced patency rates in women with CLI did not translate into differences in limb salvage. These findings might help define physician and patient expectations for women before revascularization.

Does arthroscopic débridement with or without interposition material address carpometacarpal arthritis?

BACKGROUND: Thumb carpometacarpal (CMC) joint arthritis is a common problem in clinical practice with a variety of treatment options. Arthroscopic procedures can preserve all or part of the trapezium in the setting of treatment of basilar joint arthritis, and such procedures (even without stabilization or ligament reconstruction) have high reported success rates. However, little is documented about the limitations of these procedures in terms of patient selection, the optimal type of interposition, if any, and rehabilitation. QUESTIONS/PURPOSES: A systematic review was performed to determine the influence of (1) interposition material (manufactured, biological, or none); and (2) patient-related factors (including metacarpophalangeal joint hyperextension, ligamentous laxity, and severity of arthritis) on pain, functional scores, and postoperative complications unique to each approach. METHODS: A systematic review of the English language literature regarding thumb basilar joint arthritis and arthroscopic partial trapeziectomy or débridement was performed. Those procedures including ligament reconstruction or stabilization were excluded. RESULTS: Biological materials and no interposition were both associated with satisfactory improvement and low rates of complications; complication rates with synthetic materials were higher. Eaton Stages I to III were treated successfully with this technique. The effect of scaphotrapeziotrapezoid (STT) changes was variably described across series. In most series, metacarpophalangeal hyperextension did not seem to have an adverse effect on outcomes, although these patients were excluded in some series. CONCLUSIONS: Arthroscopic débridement with or without interposition can be used for treatment of Eaton Stages I to III CMC osteoarthritis with satisfactory outcomes. Some series suggest satisfactory outcomes in the setting of STT changes and metacarpophalangeal hyperextension.

Scapholunate interosseous ligament injuries: a retrospective review of treatment and outcomes in 82 wrists.

PURPOSE: To compare outcomes of treatment for scapholunate instability between acute (< 6 wk from injury) and chronic (> 6 wk) injuries, between complete and partial tears, and among surgical techniques; identify risk factors for surgical failure; and compare ligament reconstruction with repair with or without capsulodesis in the chronic period. METHODS: We performed a retrospective chart review of 82 primary scapholunate interosseous ligament surgeries, with median follow-up of 150 days. A total of 27 patients underwent surgery in the acute period and 50 in the chronic period. (In 5 patients we were unable to determine acuity or chronicity of injury.) In the chronic period, 16 patients underwent repair with or without capsulodesis, 27 underwent ligament reconstruction, and 7 underwent other procedures. RESULTS: Surgical intervention in the acute setting involved more complex injuries, most commonly used direct repair, and produced a significantly lower failure rate than chronic intervention. In the chronic setting, the most common technique was ligament reconstruction, which produced superior radiographic outcomes compared with repair with or without capsulodesis. Isolated scapholunate interosseous ligament injuries undergoing chronic surgical intervention composed the majority of failures. Workers' compensation status and chronic intervention were significant risk factors for failure. CONCLUSIONS: For chronic injuries, ligament reconstruction produced better radiographic outcomes than repair with or without capsulodesis. Acute intervention (within 6 wk) was preferable to chronic intervention for scapholunate interosseous ligament injuries, and a substantial number of isolated injuries failed to receive treatment in the acute period. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Surgeon variation in rates of surgery for trapeziometacarpal osteoarthritis in the United States.

We identified wide variation in surgery for trapeziometacarpal osteoarthritis among surgeons in the United States, with 42% performing no surgery, a median rate of surgery of 1.9/year, and 2% performed more than 30 procedures annually, representing 15% of all surgical procedures for TMC arthritis.

Parsing the toxicity paradox: Composition and duration of exposure alter predicted oil spill effects by orders of magnitude.

Oil spilled into an aquatic environment produces oil droplet and dissolved component concentrations and compositions that are highly variable in space and time. Toxic effects on aquatic biota vary with sensitivity of the organism, concentration, composition, environmental conditions, and frequency and duration of exposure to the mixture of oil-derived dissolved compounds. For a range of spill (surface, subsea, blowout) and oil types under different environmental conditions, modeling of oil transport, fate, and organism behavior was used to quantify expected exposures over time for planktonic, motile, and stationary organisms. Different toxicity models were applied to these exposure time histories to characterize the influential roles of composition, concentration, and duration of exposure on aquatic toxicity. Misrepresenting these roles and exposures can affect results by orders of magnitude. Well-characterized laboratory studies for <24-hour exposures are needed to improve toxicity predictions of the typically short-term exposures that characterize spills.

Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England.

OBJECTIVE: Prior studies of gender differences in abdominal aortic aneurysm (AAA) repair suggest there may be differences in presentation, suitability for endovascular aneurysm repair (EVAR), and outcomes between men and women. METHODS: We used the Vascular Study Group of New England database to identify all patients undergoing EVAR or open AAA repair. We analyzed demographics, comorbidities, and procedural, and perioperative data. Results were compared using the Fisher exact test and the Student t-test. Multivariable logistic regression and Cox proportional hazards modeling were performed to identify predictors of mortality. RESULTS: We identified 4026 patients (78% men) who underwent AAA repair (54% EVAR). Women were less likely than men to undergo EVAR for intact aneurysms (50% vs 60% of intact AAA repair; P < .001) but not for ruptured aneurysms (26% vs 20%; P = .23). Women were older (median age, 75 vs 72 years for intact; P < .001; 78 vs 73 years for rupture; P < .001) with smaller aortic diameters (57 vs 59 mm for elective; P < .001; 71 vs 79 mm for rupture; P < .001). Arterial injury was more common in women (5.4% vs 2.7%; P = .013) among patients undergoing EVAR for intact aneurysms. Women stayed in the hospital longer (4.3 vs 2.7 days; P = .018) and had lower odds of being discharged home, even after adjusting for age. Among patients undergoing open repair for intact aneurysms, women more frequently experienced leg ischemia/emboli (4% vs 1%; P = .001) and bowel ischemia (5% vs 3%; P = .044). Women had higher 30-day mortality after OAR for intact (4% vs 2%; P = .03) and rupture (48% vs 34%; P = .03) repairs. However, 30-day mortality after EVAR was similar for intact (1% in men vs 1% in women; P = .57) and rupture (29% in men vs 27% in women; P > .99) repairs. Late survival was worse in women than men only for patients undergoing open repair of ruptured aneurysms (hazard ratio, 1.8; 95% confidence interval, 1.0-3.1; P = .04). After controlling for age, type of repair, urgency at presentation (ie, elective/intact vs ruptured), comorbidities, and other relevant risk factors, gender was not predictive of 30-day or 1-year mortality. CONCLUSIONS: Women with AAAs are being treated at older ages and smaller AAA diameters and are undergoing rupture repair at smaller diameters than men. Women are more likely to experience perioperative complications as a result of less favorable vascular anatomy. Age >80 years, comorbidity, presentation, and type of repair are more important predictors of mortality than gender.